Today's Date: (required) Patient Name: (required) Species: (required) Dog Cat Age/DOB: (required) Gender: (required) Male/Neutered Male/Intact Female/Spayed Female/Intact Unkown Color: (required) Breed: (required) Appointment Date: (required) Appointment Time: (required) Who will be bringing your pet to their appointment (first and last name)? (required) Vehicle (color/make/model): (required) Best phone number to reach this person during this appointment: (required) Email: (required) Is this person authorized to make medical decisions for this patient? (required) Yes No What is the primary reason for this appointment? (Please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility): (required) Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? (required) Yes No Do you have pet insurance for this pet? (required) Yes No Which flea/tick medication do you use? (required) Last date given: (required) List all other medications and supplements your pet is currently taking (medication/supplement name, dose, frequency): (required) Do you need refills of any medications/supplements today? (required) Yes No What are you feeding? (required) Wet food only Dry food only Mixture of wet & dry food People food Raw diet Home-cooked diet Treats/other Do you need refills of any prescription diets? (required) Yes No How is your pet's appetite? (required) Normal Increased Decreased Comments: How is your pet's thirst level? (required) Normal Increased Decreased Comments: Has your pet had any nausea, vomiting or regurgitation? (required) Yes No How are your pet's bowel movements? (required) Normal Abnormal Does your pet experience flatulence (gas)? (required) Yes No How is your pet's urination? (required) Normal Abnormal How is your pet's energy/activity level? (required) Normal Abnormal Comments: Please check which, if any, your pet has experienced in the past 2 weeks: Coughing Sneezing Has your pet ever had a seizure? (required) Yes No Does your pet have any behavior issues? (required) Yes No Do you provide any home dental care? (required) Yes No Has your pet been prescribed any anti-anxiety medications to help decrease fear, anxiety or stress during vet visits? (required) Yes No Is there any thing else you would like to discuss during your pet's visit today? (required) Yes No
(required) I understand that access to the BridgeMill Animal Hospital building is limited to employees and pet patients only at this time due to the COVID-19 pandemic. For everyone’s safety, I understand that I must wear a facemask at all times during any direct interactions with the BridgeMill Animal Hospital team. I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone.